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In 2011, the Institute of Medicine released a report that examined LGBT health and health disparities through the life stages. Adolescence is characterized by the transition from being a dependent child to an independent young adult. It is complicated by the physical and emotional changes that occur during puberty. Early and middle adulthood, here considered together, is roughly the period from the early 20s to the 60s. It begins with the ending of puberty and continues through the completion of formal education and the establishment of financial independence. For some it includes the selection of a partner and building a family, whether this means the introduction of children or a close community of friends. Later adulthood is then a period of continued growth but also, for many, the onset of disease. During this period, LGBT people may become dependent on health care providers and feel uncomfortable disclosing their LGBT identities. Although many of the stages that follow can occur at any stage of life, they are listed during the stage in which they most commonly occur.
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LGBT adolescents are particularly vulnerable to the emotional distress of coming out, and this distress can make adolescent development even more difficult (see Chapter 13). Adolescents who self-identify as lesbian or gay prior to consensual sexual experiences may have a more rapid progression through the coming out stages, have fewer or no heterosexual encounters, and may engage in less risky sexual experiences. Cultural factors, such as race and ethnicity, do not seem to hamper the formation of identity but may delay the integration of identity with behavior.
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Parental acceptance of the adolescent during the coming out process may be the primary determinant of healthy self-esteem. Research by Ryan et al. (see Suggested Readings) demonstrated that teens that have been rejected by their families are more than eight times more likely than their cohorts to have attempted suicide. They were also more likely to suffer from depression, anxiety, and low self-esteem, to perform worse in school, and more likely to engage in risk-taking behaviors such as high-risk sexual behavior or substance abuse. Teens that come out in school may be more likely to be teased or bullied and even threatened with a weapon. In many instances, these teens feel unsupported by teachers or parents. Indeed, teens may feel fearful of or bullied by their parents or siblings and feel unsafe at home. This can lead to increased feelings of isolation, hopelessness, and suicidality.
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Primary care providers need to screen for signs that adolescents are questioning their sexual orientation. These signs may include depression, diminished school performance, alcohol and substance abuse, acting out, and suicidal ideation. Providers noting these signs need to consider distress regarding sexual orientation in the differential diagnosis, along with depression and substance abuse. Providers also need to be willing to discuss sexual orientation with their adolescent patients, as their attempts to discuss same-sex attractions and homosexual orientations may be the patient’s first disclosure of these feelings. If providers meet such reaching out with reticence, dismay, or contempt, then adolescents may be less likely to share their feelings with others and either revert to denial or engage in more covert, risky behaviors.
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In the past, LGBT individuals have sought out others in the community by finding bars, social clubs, or community spaces frequented by other LGBT people. This is difficult in more rural areas or where the population of LGBT people is sparse or where many people are not out. The Internet, and more specifically social media, allows LGBT individuals to network with people worldwide. An adolescent is no longer isolated to his or her geographic location, but can find a social support network on the Internet on social networking sites. This access is not without risk, however. Some data show that LGBT people meeting others like themselves online also may engage in increased risk behavior (both sexual risk taking and substance abuse), particularly among men who have sex with men (MSM) who use such sites to meet sex partners. These data have so far been inconclusive and the risks must be weighed with the benefits.
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Many LGBT individuals experience support and nurturing from their biological families after coming out to them. For others, the support network of LGBT individuals may not include their biological family, as many families do not accept the sexual orientation or gender identity of the individual. In either situation, partners, friends, and community organizations can serve as an extended family. Primary care providers should be aware of a few useful resources to which they can direct patients (some resources are listed at the end of this chapter). LGBT people in rural or suburban geographic areas may have difficulty in accessing community-based support networks available in urban environments. In a study focused on MSM, those outside concentrated urban areas were less likely to identify as gay, be in a long-term relationship, be involved in a gay community, and were more likely to be out to a smaller number of people. In rural areas, a caring, open-minded physician may be an especially important source of support for LGBT patients.
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Like most heterosexuals, the majority of LGBT people express a desire to find a partner and develop a relationship. And like heterosexuals, LGBT people can form and maintain long-lasting relationships. LGBT couples have commitment ceremonies and get married (in some localities), own homes together, share finances, and raise children. Physicians should be aware of local, state, and federal laws that allow LGBT individuals to codify their relationships with partners and children, ensure health care and retirement benefits, document advance directives, and secure inheritance rights.
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Because of potential isolation from family, coworkers, and religious organizations, the relationship with a partner can be particularly important to an LGBT individual’s well-being. As a result, discord in the relationship may be even more stressful than it might be for heterosexual couples. In times of relationship stress, an individual may have limited resources for help in coping. Primary care providers should screen for such stressors and be able to provide appropriate referrals for individual and couple therapy.
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Parenthood plays a role in the lives of many LGBT people, and the decision to become parents is usually deliberate and carefully made. LGBT individuals or couples may have children from previous heterosexual relationships or through adoption, artificial insemination, in vitro fertilization and surrogacy, heterosexual intercourse, or service as foster parents. Dual gay and lesbian couples raising children together is becoming more common.
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Studies of the attitudes of gay and lesbian couples toward parenting find more similarities than differences compared with heterosexual couples. Children of gay or lesbian parents are no more likely to be gay or lesbian or to have gender identity confusion than the general population. Current evidence indicates that children of gays or lesbians develop normally and fare better in relationships where parents share responsibilities equally and have a low level of interpersonal conflict. Though they may face additional stigma in the school or community, children of gay or lesbian parents, like all children, are resilient and cope well with this challenge. Many professional medical associations, including the American Academy of Pediatrics and American Medical Association, have policies supporting same-sex, co-parent adoption.
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Because there are varying degrees of disclosure, older individuals may be “out” to themselves and a partner or close friends but no one else beyond that trusted circle. Older gay, lesbian, or bisexual individuals are vulnerable to social isolation, and primary care providers are often among the primary support resources for older individuals. Older individuals are more likely to engage in same-sex sexual experiences prior to self-identifying as gay or lesbian than adolescents and thus may be at greater risk for adverse health consequences because of risky sexual behavior. In exploring the social support network for their older patients, primary care providers need to be alert to the possibility of a lesbian or gay identity and the needs this engenders.
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Grieving the loss of a partner may be more difficult for a lesbian or gay man if that person does not have an adequate support system. Gay men and lesbians have been particularly affected by the deaths of partners and many friends from AIDS. When a partner dies, the survivor, in effect, loses a spouse. This fact often goes unrecognized in the survivor’s own social network. Frequently, the family of the deceased partner excludes the survivor or will not allow him or her to take part as a spouse in the funeral. A close-knit network of surviving friends is often neglected when a grieving family takes over funeral plans.
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Occasionally, parents and family of the deceased are shocked and embarrassed to learn of the individual’s sexual orientation or gender identity. In such cases, the family may feel intense guilt or the need to hide their grief, unable to share it with their support network because of embarrassment. Family members of gay or lesbian individuals can find information and support for this and other issues by contacting Parents and Friends of Lesbians and Gays, a national organization with local chapters (see the list of resources at the end of this chapter).
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Primary care providers can assist surviving partners and friends in the grieving process in several ways. Providers can assist the survivor in talking about the loss and expressing his or her feelings, identify and interpret normal grieving behavior and timelines, provide ongoing support throughout the grief process, encourage the survivor to develop new relationships and support structures, and help the survivor adapt to new roles and patterns of living. In some cases, the health care provider may be the only individual in whom the survivor can confide.
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The durable power of attorney for health care is particularly important for lesbians and gay men. Because many are unable to marry legally, LGBT individuals need to execute these documents to appoint their partners as surrogate health decision makers. Without such a document, current law considers the next of kin as the surrogate decision maker. Completing this document is the best way to avoid tragic decision-making conflicts between a partner and the estranged family members of seriously ill patients in time of crisis. As with all patients, providers should include a discussion of advance directives in the preventive medicine check up (see Chapter 40).